INFORMED CONSENT

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The following named individual has made application to volunteer with this entity.

Date:

YYYY

Name

Please include your middle name as well:

First Name

Last Name

Maiden, Alias or Former Name:

Home Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Address (if you have resided at your current address for fewer than 5 years)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth:

YYYY

Gender:

Male

Female

Social Security Number:

Driver's License or State ID #:

State ID Issue:

I authorize Protect My Ministry to disclose all criminal history record information to The Evangelical Free Church of Redwood Falls for the purpose of volunteering with this entity. The expiration of this authorization shall be one year from the date of my signature.

Signature of Applicant:

Date:

YYYY

Print Name:

Email:

Signature of Notary:

Date:

YYYY

You have the right, upon written request made within a reasonable time after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report prepared by contacting the Evangelical Free Church of Redwood Falls and Protect My Ministry 14499 N. Dale Mabry Hwy., Suite 201 South, Tampa, FL 33618; Phone: 1-800-319-5581. For information about Protect My Ministry’s privacy practices, see www.protectmyministry.com.

INFORMED CONSENT

"We are people, just like you, gathered in the presence of the Lord, for the Gospel to reach and restore us all."

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